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ORIGINAL ARTICLE Table of Contents  
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The association between body image, self-esteem, and body mass index in patients with schizophrenia at a tertiary care unit: A case–control study


1 Associate Professor, Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
2 Postgraduate, Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India
3 Professor, Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

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Date of Submission24-Dec-2021
Date of Acceptance09-Apr-2022
Date of Web Publication17-May-2022
 

  Abstract 


Background: When compared to the general population, patients with schizophrenia are more likely to have a higher body mass index (BMI). As a result, they are more likely to have low self-esteem, poor quality of life, and poor drug adherence.
Aims and Objectives: The aims and objectives of the study are to compare the body image and self-esteem in patients on treatment for schizophrenia with healthy controls and study the association of BMI with body image and self-esteem in them.
Setting and Design: This was a case–control study, comprising 50 patients with schizophrenia who attended the outpatient clinic of our tertiary health-care unit's department of psychiatry and 50 healthy controls.
Materials and Methods: Sociodemographic data were obtained, and BMI was computed. Body image was assessed using the Body Weight, Image, and Self-Esteem Evaluation Questionnaire (B-WISE), and global self-worth was measured using the Rosenberg Self-Esteem Scale for all participants.
Statistical Analysis: Chi-square test/Fisher's exact test was used to assess independent variables and their distribution across the study groups. Mann–Whitney U-test was used to compare the means of continuous variables across the study groups. Pearson and Spearman correlation tests were done to study the association between clinical variables. It was done using IBM SPSS 22 Program on the windows operating system.
Results: The schizophrenia group differed from the control group in marital status (P = 0.012) and educational level (P = 0.001) calculated using the Chi-square test. They also differed significantly in terms of BMI (P < 0.001) and self-esteem (P < 0 .001) assessed using the Mann–Whitney U-test. There was no significant difference in B-WISE scores between the groups (P = 0.0451). Spearman correlation revealed a positive correlation between B-WISE scores and self-esteem scores, a negative correlation between BMI and self-esteem scores, and between BMI and B-WISE scores among the cases.
Conclusion: Patients with schizophrenia had lower self-esteem and increased BMI compared to controls. Patients with a better body image had more self-esteem. Patients with greater BMI had poorer body image and lower self-esteem.

Keywords: Body image, body mass index, Mann–Whitney U-test, quality of life, schizophrenia, self-esteem


How to cite this URL:
Pindikura RK, Javangula SK, Kumar K U. The association between body image, self-esteem, and body mass index in patients with schizophrenia at a tertiary care unit: A case–control study. Arch Ment Health [Epub ahead of print] [cited 2022 Nov 29]. Available from: https://www.amhonline.org/preprintarticle.asp?id=345402





  Introduction Top


Schizophrenia is one of the most debilitating psychiatric disorders and is classified by the World Health Organization as one of the top ten diseases that contribute to the global disease burden.[1] The disorder causes severe personal, social, and occupational impairment with disturbances of self-experience and low self-esteem.[2]

Factors contributing to weight gain in schizophrenic patients include physical inactivity, genetic susceptibility, unhealthy food habits, and most importantly, the use of psychotropic medications.[3],[4] Studies have shown that around 41%–53% of these patients show poor medication adherence due to increased body weight.[5]

Body image can be conceptualized as a multidimensional construct describing how individuals think, feel, and act concerning their physical attributes.[6] Changes in the subjective body image could lead to low self-esteem and poor medication compliance.

Self-esteem can be defined as neither a static trait nor a transient state but a self-concept that is fluctuating and amenable to feedback either from self-evaluation or social milieu.[7] Many studies done on schizophrenics have found links between self-esteem and social functioning,[8] subjective quality of life (SQoL),[9] depression,[10] weight gain,[11] and psychotic symptoms.[12] Low self-esteem could either be a possible outcome or cause of psychiatric symptoms.[13] Self-stigma is an important factor in an individual's SQoL and is mediated by self-esteem.[14]

There is limited literature looking at body image and self-esteem in patients with schizophrenia. Management of negative body image and low self-esteem remains an unmet need in the treatment of the illness. This research was conceptualized and executed to fill in these gaps.

Aims and objectives

  1. To compare body image and self-esteem in patients on treatment for schizophrenia with healthy controls
  2. To study the association of body image, self-esteem, and body mass index (BMI) in patients with schizophrenia on antipsychotic treatment.



  Materials and Methods Top


Design

This is a case–control study. The cases and controls were recruited between June 2021 and October 2021 from the outpatient department (OPD) of our tertiary care institute. The cases were drawn from patients attending the OPD and the controls were the caregivers accompanying the patients.

Sampling method – The patients were chosen by consecutive sampling among the patients attending the OPD and fulfilling the inclusion and exclusion criteria until the required sample size was achieved.

Sample size – It was done using G-Power software with the level of significance α = 5%, power 1−β = 80%, and effect size d = 0.65. A sample size of 100 was obtained by this calculation with 50 cases and 50 controls.

Selection criteria

Inclusion criteria


  Cases Top


  • Patients diagnosed with schizophrenia according to the International Classification of Diseases-10
  • Patients on treatment for the past 6 months and a stable dose of antipsychotic medications (no change in the dose since the past 3 months)
  • Those schizophrenic patients scoring <7 on Hamilton Depression Rating Scale (HDRS).



  Controls Top


  • Weight, ±5%, gender, and age ± 5% matched healthy individuals consenting for the study
  • Men scoring <8 and women scoring <10 on the Self-Reporting Questionnaire 20-item (SRQ-20).


Exclusion criteria


  Cases Top


  • Uncooperative patients due to illness severity
  • Those patients having somatic delusions
  • Patients with mental retardation, head injury, seizures, and any other chronic medical comorbid illnesses.



  Controls Top


  • Not on any long-term medications


Materials

Sociodemographic profile sheet

It consists of semi-structured pro forma with certain variables such as age, gender, marital status, education, and residence.

Body mass index calculation

BMI = weight in kilograms divided by the square of height in meters.

Body weight, body image, and self-esteem questionnaire

This questionnaire is developed to quantify the psychological and social impact of weight gain in patients on long-term psychotropic medications.[15] It is a 12-item self-report questionnaire. The items are statements explaining the subjective evaluation of an individual's improvements in body weight and psychosocial adjustments in the previous 2 weeks. It shows high internal consistency (Cronbach's α: 0.79) and equal split reliability (Spearman–Brown coefficient of 0.76) psychometric properties.[16]

Rosenberg Self-Esteem Scale

It is a unidimensional 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. Using a 4-point Likert scale format, the items are measured from strongly agree to strongly disagree with 4 and 1 points, respectively. Items 2, 5, 6, 8, and 9 are reverse scored. Higher scores indicate better self-esteem. This scale showed adequate internal consistency (α-coefficient: 0.83).[17]

Self-reporting questionnaire

It is an instrument that was developed by the World Health Organization to screen for psychiatric disturbances, especially in developing countries. It consists of 20 questions answered with either yes or no. The SRQ-20 items are scored 0 for no symptom or 1 for symptom present. The optimal cutoff for men is 8 and for women is 10. The scale shows good inter-rater reliability (correlation was 0.978, F = 174.98) and validity of kappa value 0.48 with General Health Questionnaire-12 as the gold standard.[18]

Hamilton Rating Scale for Depression

This is the most widely used clinician-administered scale for the assessment of depression. It has 17 items related to depressive symptoms experienced by a person over the past 7 days. A score of <7 is considered to be under clinical remission. Patients scoring over 7 on this scale were excluded from our study. This was done to avoid those patients whose reduced self-esteem could be due to depressive disorder.[19]

Methodology

The study was commenced after getting ethical clearance from the institutional review board. From all the cases and controls who fulfilled the inclusion criteria, written informed consent was obtained after the study details had been explained to them in their native language.

Data were collected on the sociodemographic variables; height and weight were measured, and BMI was calculated. The Bodyweight, Image, and Self-esteem Evaluation questionnaire (B-WISE) was used to examine body image and the Rosenberg self-esteem scale (RSES) for self-esteem. HDRS was used to rule out depression in cases, and SRQ-20 was used as a screening tool to recruit participants to the control group. All the assessments were done only once in our study.

Statistical analysis

It was done using IBM SPSS 22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) program on the windows operating system. Chi-square test/Fisher's exact test was used to study independent variables and their distribution across the study group. Nonparametric Mann–Whitney U-test was used to compare the means of continuous variables across the study groups as these variables were not normally distributed. Correlation between continuous variables was studied by Spearman and Pearson bivariate correlation tests. P < 0.05 was considered to be statistically significant.


  Results Top


The mean age of the participants in the study was 34.528 ± 7.54 years. There were 25 (50%) male and 25 (50%) female participants in both the case and control groups. The majority of the patients were from a rural background, single, received primary education, and had an overweight BMI in the case group. The participants in the control group were mostly from a rural background, married, received education up to secondary level, and had an overweight BMI.

The mean score on B-WISE scale for cases was 25.75 ± 2.66 and their mean score in the Rosenberg scale was 12.09 ± 1.08 [Table 1]. Among controls, the mean score in the B-WISE scale was 25.82 ± 1.51 and the Rosenberg scale was 15.65 ± 1.14.
Table 1: Body image and self-esteem of cases and controls

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The association between sociodemographic variables among the case and control groups was explored using Chi-square and Fisher's exact test [Table 2]. There was no significant association between the study groups in the region of the participants but a statistically significant difference in variables such as marital status and education.
Table 2: Sociodemographic variables and their association with study population groups

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Mann–Whitney U-test was done to compare the body image (B-WISE), self-esteem (Rosenberg), and BMI across cases and controls. There was no statistically significant difference between scores of cases and controls on B-WISE. Cases and controls had similar psychosocial adjustments to body image. There was a statistically significant difference between scores of cases and controls on RSE and also on BMI scores. Cases had lower self-esteem and higher BMI compared to controls [Table 3].
Table 3: Comparison of body image, self-esteem, and body mass index scores between cases and controls using Mann–Whitney U-test

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We found a positive correlation between B-WISE scores and self-esteem scores in the schizophrenia case group using Spearman's nonparametric correlation, and it was statistically significant [Table 4]. Cases with better psychosocial adjustments to body image had more self-esteem. There was a statistically significant negative correlation between B-WISE scores and BMI scores in schizophrenia cases [Table 5]. Schizophrenic patients with lower BMI scores had a better psychosocial adjustment to body image. There was also a statistically significant negative correlation between BMI scores and self-esteem scores in schizophrenic cases [Table 6]. Patients with lower BMI had more self-esteem.
Table 4: Correlation between Body Weight, Body Image, and Self-Esteem Questionnaire e scores and self-esteem scores

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Table 5: Correlation between Body Weight, Body Image, and Self-Esteem Questionnaire scores and body mass index scores

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Table 6: Correlation between body mass index scores and self-esteem scores

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  Discussion Top


The two study groups had similar mean age and gender distribution because we matched controls and cases. In the marital status, it was noted that among the cases, 35 (70%) were single and only 15 (30%) were married. In the controls, 23 (46%) of them were single and 27 (54%) were married with a statistically significant value of P = 0.013, that is, unmarried status was significantly associated with the risk of schizophrenia in our study. It was in agreement with earlier studies like Thara and Srinivasan[20] who showed that being singles were more common in schizophrenia than the general population. Most of the participants in the schizophrenia group had primary education (74%), whereas in the control group, more of them had secondary education (50%), which was statistically significant with P = 0. 001. The findings were similar to studies done by Kendler et al.[21] who reported that most schizophrenic patients were unemployed due to less or primary education.

On B-WISE scores, both the groups showed no statistically significant differences. Despite the schizophrenic patients having higher BMI in our study, there was no difference in body image perception compared to the healthy controls which were also observed in a study done by Arbour-Nicitopoulos et al.[22] However, among schizophrenics, higher BMI predicted poorer body image perception as can be seen by its negative correlation with the B-WISE scores, which was in line with the study by De Hert et al.[11] in 2006, but not in line with the study by Arbour-Nicitopoulos et al.[22] We found statistically significant differences between scores of cases and controls on the Rosenberg scale (U = 1,381; P < 0.001). The schizophrenia group had lower self-esteem than controls, similar to a previous study done by Rizwan and Ahmad.[23] in 2015. We also found higher BMI in schizophrenic patients than in the control group, which was statistically significant (P < 0.001). Similar findings were reported by the study done by Coodin.[24]

There was a positive correlation between B-WISE scores and self-esteem scores in the schizophrenia group (rs = 0.397, P = 0.01) using Spearman's nonparametric correlation. Patients with better psychosocial adjustments to body image had more self-esteem as is expected. It was in line with the studies done by Strassnig et al. in 2005[25] and Awad and Voruganti[16] in 2004. We found a negative correlation between B-WISE scores and BMI in the schizophrenia group (rs = −0.359; P = 0.23). Obese and overweight patients had a poorer body image compared to those with normal BMI. There was a negative correlation between BMI scores and self-esteem scores in the schizophrenia group (rS = −0.248; P = 0.32). Patients with higher BMI scores had poorer self-esteem. Similar findings were reported by Oh et al. in 2017 in a study done in Korean patients with schizophrenia; they reported that self-esteem in patients with schizophrenia was influenced by BMI and body image.[26]

There were some limitations in our study. We did not take into account the duration of treatment or the class of antipsychotics used for medication which could have a considerable effect on our patient's weight gain, body image perception, and self-esteem. Schizophrenia symptomatology was not assessed using any scales. Ours was a cross-sectional assessment and hence could not pick up any variations in body image and self-esteem related to fluctuating body weight during treatment with antipsychotics. We also did not assess physical activity levels which probably would have a considerable influence on BMI and hence on body image and self-esteem on our patients. Interventions in clinical practice to address weight gain and understanding body image and self-esteem are important as they influence adherence to antipsychotics in patients with schizophrenia. We recommend researchers use a longitudinal study design, assess physical activity levels, and also take into consideration the class of antipsychotics used for further studies.


  Conclusion Top


Schizophrenic patients had lower self-esteem than their controls. Their BMI was higher than the control population. Patients with better psychosocial adjustments to body image had more self-esteem. Patients with greater BMI had poorer psychosocial adjustments to body image and lower self-esteem. Clinicians should monitor for weight gain, address body image, and self-esteem issues as a part of their routine practice which would further enhance their patient's adherence to medications and also improve their quality of life. Future studies with a longitudinal design and also assessing physical activities would be beneficial.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Correspondence Address:
Ranjit Kumar Pindikura,
Department of Psychiatry, Narayana Medical College and Hospital, Nellore, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amh.amh_194_21




 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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    -  Javangula SK
    -  Kumar K U


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